July 24, 2013 - Fact: More and more people in this country are living longer with a greater-than-ever number of chronic diseases.

Fact: One in four Medicare dollars--more than $125 billion a year--is spent on services for only 5 percent of beneficiaries in the last year of their lives, according to the Centers for Medicare and Medicaid Services (CMS).

Fact: There is a growing shortage of specially trained palliative care nurses and physicians.

The challenge: To care for the growing population of chronically ill in a more knowledgeable, compassionate and cost-effective manner.

How to do it?

One obvious answer is to train more nurses and physicians in the intricacies of palliative care, but that may be easier said than done. Data from the American Academy of Hospice and Palliative Medicine indicates that at least 15,000 palliative care physicians will be needed by 2024, but currently only about 200 a year receive training.

As for nurses, fellowships and certification programs are available, said Marlene McHugh, DNP, DCC, FNP-BC, ACHPN, but not nearly enough--especially when the goal is to provide training for every nurse who works with chronically ill patients. McHugh serves as an assistant clinical professor at the Columbia University School of Nursing and practices in palliative care at Montefiore Medical Center in the Bronx, N.Y.

“Nurses and doctors will need to combine palliative care, med management and critical care,” McHugh says. “Anyone who works in these areas is going to have some level of palliative care education. Nurses make excellent palliative care specialists because the principles of palliative care are integral to the scope and standards of …all specialty areas of nursing practice.”

Others also believe that nurses are uniquely equipped to work in this field.

“We need to see more advanced practice nurses in palliative care,” agreed physician Sean O'Mahony, MB, BCh, BAO, director of the section of palliative medicine and professor of medicine and nursing at Rush University Medical Center in Chicago. For instance, “Nurses are more oriented around serving patients and families. They have better knowledge of community services and access to resources. They are more comfortable with ‘reflective silence’ when patients receive the bad news.”

Palliative care, according to the World Health Organization (WHO), is an approach to treatment that improves the quality of life for both patients and families who face life-threatening illnesses. The goal is to relieve suffering by identifying clients’ needs early on, including physical, psychosocial and spiritual needs.

McHugh helped found one of the few acute palliative care units (APCU) in the country. It serves Montefiore patients who want to continue a level of intensive care, but also want to take advantage of the palliative care philosophy.

“This unit is very different and very new, and something that we put together based on what we were seeing in the hospital,” explained the 28-year veteran nurse whose background includes oncology, med–surg, medical ICU and primary care in underserved communities. “Establishing APCUs allows patients to leave the ICU but still receive a high level of care, but there is a greater degree of focus on the patients’ values and treatment preferences, as well as support for their families.”

McHugh recently co-authored a study comparing the cost of care for cancer patients in the last month of life in Montefiore’s APCU with that of ICUs in 137 other academic medical centers. Montefiore’s APCU costs were more than 12 percent lower than the ICUs.

The study was published in the American Journal of Hospice & Palliative Medicine in June.

“The (financial) benefits are more likely to occur when patients are directly managed by those trained in chronic disease management, as well as family and end-of-life counseling,” McHugh said. “They…can assist patients and families in the transition from aggressive treatment to palliative care.”

O’Mahony recommends that both physicians and nurses spend at least a year or two working in primary care, ICU or the ER before seeking training in palliative care.

“People often go straight from undergrad to grad courses in palliative care, but they need to see high volumes of patients and have a good background of experience first,” he recommended.

An opinion piece in the March 13 issue of the New England Journal of Medicine (NEJM), written by palliative care physicians, envisioned a two-tiered system--advanced palliative care specialists and the generalists. The latter are nurses and doctors in specialized areas who have been trained in “basic palliative skills.” They will know when to call in the specialists, who will have additional years of training in things such as “negotiating a difficult family meeting, addressing veiled existential distress, and managing refractory symptoms.”

The generalists are necessary, the authors say, because of the sheer number of patients who will require such services and the prohibitive costs of employing specialists in every case.

Just how health care professionals will learn these skills is a challenge because the current number of training programs is inadequate, say the NEJM authors. At the very least, each medical specialty should devote some of its curriculum to basic palliative care, including a “triage system for calling on palliative care specialists when necessary.”

For nurses, the End-of-Life Nursing Education Consortium (ELNEC) has developed both general and advanced palliative care courses. The curriculum includes modules on pain and symptom management; ethical and legal issues; cultural considerations and more. The Hospice and Palliative Nurse Association (HPNA), established in 1986, offers a certification program.

“This is all about moving palliative care upstream,” McHugh says. “Institutions are starting to allow nurse-generated, palliative care consults. Eventually I see [mandatory palliative care training] as part of JCAHO standards.”